Stephanie Nickdorf was at Disney World with her family when she received the call in December 2021. The mysterious bump in her elbow was melanoma, her doctor said. Tests later showed that it was stage 4, with spots in the lungs and two tumors in the brain.
Nickdorf, 51, is a mother of four who lives with her husband Jason in Davidson, North Carolina, and soon began treatment, and by January 2024 her cancer had faded. Premera Blue Cross Health Insurance, provided by her husband's employer, covered her cancer care, but refusal began in early 2024 when Stephanie's doctor prescribed medications to combat crippled arthritis induced by immunotherapy treatments.
“I used to run, play tennis and get active,” Nixdorf told NBC News. “Now I can't open yogurt or even grab the wheel in the morning.”
Premera Blue Cross, a non-profit licensee for the Blue Cross Blue Shield Association in Mount Lake Terrace, Washington, is a major health plan for the Pacific Northwest, serving 2.5 million people. For nine months in 2024, repeated requests from Nixdorf doctors refused to cover Infliximab, a prescribed inflammatory arthritis drug.
His wife suffered, and Jason Nickdorff had the chance with Zach Veglis, a former chief data scientist at the Department of Veterans, who had co-founded the company to help patients fight the insurance company's denial. Its company, Claimable Inc., has built an AI platform that allows patients to generate customized appeal letters that include comprehensive assessments of clinical research on drugs or treatments. Cost: Approximately $40.
When Nixdorf reached out, the billable site wasn't live yet, but its CEO and co-founder Dr. Warris Bokhari offered to help write Stephanie's appeal using the system they developed.
In mid-September 2024, she sent that 23-page appeal to Premera's chief executive and chief attorney, saying one of her own policies should cover infliximab, according to her records, her letter was also awarded to the Governor and Attorney General of North Carolina, Department of Health and Human Services officials, Consumer Financial Protection Bureau and the Wages and Hours Division of the Department of Labor.
Two days later, Premera approved the drug. “I apologize for waiting for you to receive treatment for nine months,” the approval letter said.
Nixdorf is one of a growing cohort of patients to use artificial intelligence to combat health insurance denials. Several companies offer software programs with the help of AI, which allow patients to create comprehensive appeal letters relatively quickly. It rubs the internet for all fragments of drug efficacy and evidence of past complaints.
Courtney Wallace, a spokesman for Premera, provided a statement to NBC News regarding the NIXDORF case.
“There was no intention to deny care,” she said. Rather, Premera made “processing errors that included misuse of policy and assignments to incorrect physician professionals.”
In this case, Premera was “sufficient,” Wallace added.
Research shows that the arthritis Stephanie was experiencing can cause joint damage and serious damage without treatment.
Jason Nickdorff is relieved that his wife has been able to receive coverage of the treatment prescribed by the doctor, but he also feels angry at the ordeal and its outcome.
“Not only has the delays been permanent damage to Stephanie, it will be lifelong to dealing with this arthritis.
“People give up.”
As many patients and their doctors know, seeking insurance coverage for drugs and treatment can be a full-time, infuriating job. Although comprehensive data on insurance company denials are not available, a January 2025 survey by the health policy survey, votes and news agency KFF found that insurers participating in so-called market plans under the Affordable Care Act rejected 19% of their 2023 network claims. Less than 1% of consumers appealed to denial, and when the investigation was found and when they did, more than half (56%) of denials were supported.
In addition to the impact insurance company's refusal on the health of the patient, they are responsible for financial costs. In a 2023 KFF survey, 39% of consumers who have problems paying medical expenses said that a claim that contributed to the issue was denied.
In the fight over Premera's denial, Nixdorfs and their doctors repeatedly attempted to set up a review of the lawsuit by leaving messages that could never be answered by humans, faxing paper documents at Premera's request, and completing the medical needs.
Wallace, a spokesman for Premera, agreed that the Nixdorf incident had a “disruption of communication.” “We're focused on providing a better experience for our providers,” she added.
Nixdorf documents show that Premera's initial denial occurred in February. The insurance company said Infliximab “is not medically necessary” to treat arthritis. The second rejection in June was considered “trial or experimental” despite being recommended by oncologists for inflammatory arthritis with the Bible National Comprehensive Cancer Network Drug and Biological Compendium. The third denial in July said infliximab was not approved by the Food and Drug Administration.
“They set up a system and people give up,” Jason said.
After a third denial, Jason requested Premera to provide all records related to the decision. For example, he and his wife developed even more trouble when a doctor known as a peer-to-peer review of cases learned to be an internal medicine specialist with no expertise in cancer or inflammatory arthritis.
They also found that Premera had signed up and an independent review of their cases (all medical management) was led by Jeff Card. Jeff Card served as director of the clinical review business at Premera for seven years before joining Allmed in 2021.
Nixdorf told NBC News.
A Premera spokesperson refused to respond to the criticism, saying “Allmed is accredited by both the National Committee on Quality Assurance and the Committee on Accreditation of Use Reviews.” Premera's partnership with ALLMED “will be subject to strict monitoring, including quarterly reviews and audits,” Wallace said.
Allmed did not return emails and calls seeking comment from the company and the card.
Billable Veigulis said three co-founders of the company, including Alicia Graham, wanted to understand why people with access to healthcare don't receive it. Building an AI model released last October, they began with rheumatism and migraines and now cover over 50 life-changing treatments. Veigulis said that about 1,000 rejections have been reversed by patients using a billable model.
“We see a lot of people who meet eligibility criteria to pay premiums on time without access to healthcare yet,” he said. “It's wild.”
“You have the rights.”
Tabisally is a former paramedic who worked in rheumatology at Wilmington Health, North Carolina. Since January, she has handled the advance approval and insurance denials of around 100 patients who come in every day.
The denial has risen recently, she said.
“We've been taking many patients over the years, stable, well controlled, and insurance has denied them,” Lee told NBC News. Instead, the insurance company will suggest an approved list or a formalized alternative, she said. This was causing problems for patients, Lee added.
Lee said he tried to file an appeal with the patient, but compiled scientific and clinical laboratory data for each case took a long time. In February, at the proposal of a rheumatologist and adjunct professor at Duke School of Medicine, she began filing appeals using an AI generation system created by Counterforce Health, a nonprofit founded by Neil K. Shah, a former hedge fund manager. Shah is also the CEO of Careyaya Health Technologies. CareyayaHealth Technologies is a nonprofit organization pursuing medical degrees with families seeking care for older relatives in college students.
Counterforce generates customized appeal letters based on patient insurance and records of successful appeals related to the drug or treatment in question. The letter will also be sent to the patient's state insurance regulator to warn him of his denial.
“Refusals should be appealed, but we observe that most people don't appeal because most people are threatened overall,” Shah said. His message to the patient: “If you get no, take the next step. You have the right.”
Lee said using Counterforce software would help reverse her denial. “We regained approval on the same day and the next day,” Lee said. “It definitely limits the time it has to be spent developing each denial letter, and more work can be done with initial advance approval and patient support.”
